Your
original consultation includes 3 refills over a period of 12 months.
Remember that you may order 90 or 180 per prescription.
Each prescription is independent of the other. This allows you
to order different quantities for each refill. To receive a refill
please complete the following steps:

1.
Read and agree to the Waiver of Liability.

2.
Select the quantity of PropeciaŽ pills.

PROPECIA®
PRICES ARE AS FOLLOWS:

1 mg PropeciaŽ Pills

90 tablets = 3 month supply Total =
$249

180 tablets = 6 month supply Total =
$425

WAIVER OF LIABILITY

I
hereby release www.onlinepills.com and all of their employees and contractors
including physicians from all liability associated with my Propecia®
consultation and/or the use of Propecia®. I understand that
no physician, nurse or administrative personnel can guarantee that
Propecia®, even if prescribed, will provide the results I seek.
I hereby agree to answer truthfully all of the medical questions
during my consultation. I also understand that if I fail in
anyway to furnish www.onlinepills.com with my complete and accurate medical
history or become aware of any changes in the future which I have
not notified www.onlinepills.com of then I cannot hold them responsible for
any adverse effects I may suffer.

I
am fully aware that it is my responsibility to have an annual physical
exam, including any suggested laboratory test, to ensure that I
have no disease, which might make Propecia® inappropriate for
me. I also understand that this consultation is not a substitute
for my need to visit a local physician for my annual exam. I further agree to consult with my local physician and/or pharmacist to warrant that I am not taking any medication on the published list that would contraindicate the use of Propecia®. I further
agree to notify all physicians, whose present care I am currently
under or any physician who I will engage in the future, of my decision
to use Propecia® so they may advise to continue or discontinue
the use of medication.

I
understand that the side effects of Propecia®, which generally effect less than two percent of the population include but are not limited to; a decrease in libido, erectile dysfunction and a decrease in the ejaculate fluid (not related to sperm count). These side effects are reversible and will generally cease upon the discontinuation of the medication. Furthermore, I understand that Propecia® is for the treatment of male pattern hair loss in men only. Women who are or may potentially be pregnant must not use Propecia® and should not handle crushed or broken tablets of Propecia®. The ingredients in Propecia® may cause potential risk to the development of the male sex organs in the developing fetus. Propecia® tablets are coated and will prevent contact with the active ingredients during normal handling. For more information regarding Propecia® please contact Merck & Co @ www.propecia.com.

If approved, I irrevocably appoint www.onlinepills.com to be my agent and have my prescription and any refills filled by the Pharmacy of its choice and acknowledge that the Rx obtained for me is non-transferable. We
are unable to accept returns or issue refunds for any orders due
to the fact that this is a prescription medication.